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Trichinellosis Associated with Bear Meat --- New York and Tennessee, 2003

Trichinellosis is a parasitic infection caused by
tissue-dwelling Trichinella roundworms and is associated traditionally
with ingestion of pork from infected domestic swine. As a result of improvements in swine production, trichinellosis has
declined steadily in the United States (1). However, infection also can result from eating the meat of wild animals. During
1997--2001, a total of 72 cases of trichinellosis (median: 12 cases annually; range: 11--23 cases) were reported to CDC; the majority of these infections were associated with eating wild game, predominantly bear. This report describes three cases of
trichinellosis associated with eating undercooked bear meat reported from New York and Tennessee in
2003. To prevent trichinellosis, persons should cook meat,
particularly wild game, to an internal temperature of 160º F (71º C) (1).

Case Reports

New York. In December 2003, the New York State Department of Health was notified of a trichinellosis case in a man aged 54 years who resided in Franklin County. The patient had been hospitalized in a tertiary care center in early
November with a 3-week history of diaphoresis, fever, weakness, tachycardia, diarrhea, an 8-pound weight loss, and dry cough. Laboratory testing indicated an elevated white blood cell (WBC) count
(20,600/mm3 [normal:
5,000--10,000/mm3] with 33% eosinophils), hyponatremia (123 mmol
sodium/L [normal: 136--145 mmol sodium/L]), elevated
lactate dehydrogenase (LDH) (823 U/L [normal: 313--618 U/L]), and elevated creatinine phosphokinase (CPK) (1,554 U/L [normal: 10--250 U/L]).

The patient reported eating approximately 2 pounds of nearly raw bear meat during several meals 2 weeks before
onset of symptoms. The meat had come from a custom slaughter house in upstate New York and had been frozen at
-4° F (-20° C) for approximately 1 week before ingestion. Because of suspicion of trichinellosis infection, albendazole and corticosteroids were administered. Weakness and fatigue persisted through late December 2003. The patient recovered fully by February 2004.

Serum specimens collected on the third hospital day for antibody testing of
Trichinella and other helminths were reported
negative by a commercial reference laboratory. A serum specimen collected on the 11th hospital day and sent
to CDC for Trichinella antibody testing was positive by
enzyme-linked immunoassay.

The New York State Department of Environmental Conservation (NYSDEC)'s Wildlife Pathology Unit recovered nine packages of bear meat from multiple bears from the patient's freezer and identified
Trichinella spp. larvae in five of the
seven packages examined. Muscle digestion with artificial gastric juice yielded 0.5--48.0 larvae per gram of bear meat. The remaining two packages of meat were examined by the U.S. Department of Agriculture (USDA), which identified
Trichinella nativa by polymerase chain reaction (PCR).

Tennessee. In November 2003, the Tennessee Department of Health received a report of two cases of trichinellosis
in persons residing in Claiborne County. In early October, a man aged 38 years and a woman aged 54 years were admitted to
a hospital with 7-day and 14-day histories of fever, respectively, chills, headache, myalgias, arthralgias, and facial swelling. The man's WBC count was 14,600/mm3, with 24% eosinophils, 13% lymphocytes, and 2% monocytes. The woman's WBC
count was 16,200/mm3, with 28% eosinophils, 13% lymphocytes, and 3% monocytes. Serum obtained from both patients
tested positive for Trichinella antibodies, and both were started on a course of albendazole and corticosteroids. Both patients
have recovered fully.

Questioning of the patients revealed that, in late August 2003, the man had shot a black bear
(Ursus americanus) in Canada. The bear was field dressed, and selected meat was packed on ice for transport to Tennessee. On August 31, the man and woman prepared and cooked the bear meat on an outdoor grill for themselves and four other persons. The man and
woman ate their steaks medium rare; the four others ate their steaks well done. The remaining meat was packaged for storage in
a household freezer, and the family continued to consume the meat during September.

In December, samples of the bear meat were examined histologically at the University of Tennessee College of
Veterinary Medicine. Numerous Trichinella larvae were observed encysted in characteristic hyalinized capsules in the striated muscle
tissue (Figure). The larvae had diameters of approximately 30--35
µm, and the diagnostic morphology of the stichosome was apparent at high (400x) magnification. Further
testing of the bear meat at USDA recovered live larvae (estimated
infection intensity: 350--400 larvae per gram of muscle), and PCR results were consistent with the genotype T. nativa.

Editorial Note:

Undercooked wild game has emerged in
recent years as a predominant source for infection with
Trichinella (2,3) (Box). During 1997--2001, of the 52 (72%) U.S. cases in which a source of infection was known or suspected, pork products were associated with 21 (40%) cases, and wild game was associated with 31 (60%), including 29 cases linked to
bear meat (1). In Canada, the majority of trichinellosis outbreaks during the previous three decades were attributed to eating meat from wild animals (3).

Increasing local bear populations combined with the popularity of bear hunting in the northeastern United States
and Canada might contribute to increased cases of
Trichinella infection. In 2003, in New York state, a record number
of approximately 1,850 bears were reported killed by hunters (4). NYSDEC provides information about trichinellosis and
proper cooking instructions for wild game with each bear-hunting license issued. However, the meat from hunted animals often
is given away and eaten by persons who are unaware of the need to cook the meat thoroughly enough to kill larvae.
Multiple exposures also can occur when bear meat is served at wild game parties. Whereas freezing at specified temperatures kills
T. spiralis larvae in pork, T.
nativa is a freeze-resistant species that remains viable after freezing, even for months or years.
The three cases described in this report were the result of eating improperly cooked bear meat infected with
T. nativa.

Educational messages concerning the risks of eating meat cooked improperly do not always reach persons at risk
for trichinellosis (2). To prevent future cases of trichinellosis, health-education messages should target wild game hunters who are most at risk for Trichinella infection
(3). Information on the parasite and proper cooking should be made available at points
of wild game distribution, such as custom butchers and game meat processors. To prevent trichinellosis, consumers should
be advised to monitor for an adequate cooking temperature of
160° F (71° C)
(1) and observe the color and texture of the
meat during cooking. A change in color from red to dark gray throughout and a change in texture such that muscle fibers are
easily
separated from each other are indicators that meat has been rendered safe to eat
(3,5). However, game meats such as bear are very dark, making interpretation of color changes difficult; for these, adequate cooking might be better judged by texture and temperature. USDA recommends a higher temperature to allow for different cooking methods (e.g., microwave cooking)
that might result in uneven temperature distributions throughout the meat
(6).

Symptoms associated with classic trichinellosis from
T. spiralis include fever, facial edema, myalgias, muscle swelling,
and weakness. However, as demonstrated in the T.
nativa cases described in this report, some of these symptoms might be
absent. Eosinophilia typically is present in cases of trichinellosis, and elevated blood levels of muscle enzymes (e.g., LDH and CPK) also are common. Physicians should consider trichinellosis in any ill person with eosinophilia and a history of eating
wild game. Suspected cases should be reported to state health departments.

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